LETTERS to the EDITORTechnology-free obstetrics at the Semmelweis Clinic
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Patterns of determinants of infant mortality in developed nations, 1950-1975
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Cited by (17)
The influence of the birthplace and models of care on midwifery practice for the management of women in labour
2006, Women and BirthThis paper will examine how the settings in which midwives practice (the birthplace) and models of care affect midwives’ decision making during the management of labour. One-hundred-and-four independent, team and hospital based midwives and 100 low obstetric risk nulliparous women to whom labour care was provided were surveyed. These midwives and women resided in the Auckland metropolitan area of New Zealand. The majority of midwives who participated worked in models of care which provided women with continuity of carer and care, however, this was not found to influence the way the midwives provided labour care. Instead, practice was found to be relatively homogenous regardless of whether the midwives worked in independent, team, or hospital-based practice. The birthplace setting in which the labour care took place did influence midwifery practice. The majority of midwives provided labour care in large obstetric hospitals and identified practices dominated by the medical model of care. Practice was described as being influenced by intervention and the need for technology, however, this did not prevent the majority of women from perceiving they were actively involved in the decision making process and that they worked in partnership with their midwives. Closer examination of the midwives’ decision making processes whilst providing the labour care revealed that the midwives’ individual decisions were influenced by the needs of the women rather than the hospital protocols. What became evident was that the midwives in this study had adopted a humanistic approach to care whereby technology was used alongside relationship-centred care.
Changing American birth through childbirth education
1995, Patient Education and CounselingChildbirth educators have the opportunity to enable pregnant families to effect changes in obstetric care. Classes aimed at teaching a low-intervention model of birth are considered. Requisite class content is discussed and examples from the author's experience are offered.
Medically unnecessary cesarean section births: Introduction to a symposium
1993, Social Science and MedicineBetween 1965 and 1986, the United States cesarean section rate increased from 4.5 to 24.1%. Increasingly, childbearing women and their advocates, along with many others, have recognized that a large proportion of cesareans confers a broad array of risks without providing any medical benefit. A growing literature examines the diverse causes of medically unnecessary cesareans and the diverse effects of surgical birth on women, infants, and families. Various programs and policies have been proposed or implemented to reduce cesarean rates.
In recent decades, many other nations have also experienced a sharply escalating cesarean section rate. It is reasonable to conclude that a largely uncontrolled international pandemic of medically unnecessary cesarean births is occurring. The level of political, analytic, and programmatic activity that has occurred in the U.S. regarding medically unnecessary surgical births does not seem to be paralleled in other nations with sharply escalating rates.
This symposium was organized with the objective of presenting the U.S. experience with various dimensions of the problem of medically unnecessary cesareans to an international audience. Although preliminary and inadequate, it is hoped that this experience will encourage policy leaders and investigators throughout the world to recognize and address the problem of run-away cesarean section births.
The first section of this introduction summarizes the U.S. experience with medically unnecessary cesareans from the perpective of trends, causes, consequences, and solutions. The second section covers the same topics, presenting selected material from various other nations throughout the world. In the course of these overviews, I introduce the symposium's seven contributions, most of which focus on circumstances in the U.S.
Caesarean section in Britain and the United States 12% or 24%: Is either the right rate?
1993, Social Science and MedicineThe rate of caesarean section (CSR) in Great Britain (GB) and the U.S.A., 12% in England in 1989 ascertained from a survey performed by the authors, and 24% according to official U.S. figures, is higher than warranted by the known and agreed obstetric indications for this operation, which suggest a rate of 6–8% would be adequate.
It is argued that the fall in perinatal mortality which has occurred over the period during which the CS rate has risen is not the main reason for this fall. The training of obstetricians to deal with anxiety, provision of primary maternity care by appropriately trained midwives and general or family practitioners, and changes in management protocols could cut the CSR. The number of women undergoing surgery every year in the U.K. could be reduced by 20,000 and in the U.S.A. by 470,000 if the rate of 6% were achieved.
In studies of midwifery care the CSR is even lower and it is possible that labour proceeds more efficiently if the woman knows her caregivers and labours at home, as in The Netherlands. Although CS is much safer than in the past it is still more likely to result in the death of the woman and has significant morbidity for the woman and economic costs for society.
Midwifery care and out-of-hospital birth settings: How do they reduce unnecessary cesarean section births?
1993, Social Science and MedicineIn studies using matched or adjusted cohorts, U.S. women beginning labor with midwives and/or in out-of-hospital settings have attained cesarean section rates that are considerably lower than similar women using prevailing forms of care—physicians in hospitals. This cesarean reduction involved no compromise in mortality and morbidity outcome measures. Moreover, groups of women at elevated risk for adverse perinatal outcomes have attained excellent outcomes and cesarean rates well below the general population rate with these care arrangements.
How do midwives and out-of-hospital birth settings so effectively help women to avoid unnecessary cesareans? This paper explores this question by presenting data from interviews with midwives who work in home settings. The midwives' understanding of and approaches to major medical indications for cesarean birth contrast strikingly with prevailing medical knowledge and practice. From the midwives' perspective, many women receive cesareans due to pseudo-problems, to problems that might easily be prevented, or to problems that might be addressed through less drastic measures.
Policy reports addressing the problem of unnecessary cesarean births in the U.S. have failed to highlight the substantial reduction in such births that may be expected to accompany greatly expanded use of midwives and out-of-hospital birth settings. The present study—together with cohort studies documenting such a reduction, studies showing other benefits of such forms of care, and the increasing reluctance of physicians to provide obstetrical services—suggests that childbearing families would realize many benefits from greatly expanded use of midwives and out-of-hospital birth settings.
Reducing cesarean births at a primarily private university hospital
1993, American Journal of Obstetrics and GynecologyObjective: The rise in cesarean birth at Northwestern Memorial Hospital in 1986 to 27.3% prompted implementation of three initiatives to reverse the escalating cesarean section rate.
Study Design: First, vaginal birth after cesarean section was more strongly encouraged. Second, after the 1988 calendar year the cesarean section rate of every obstetrician was circulated annually to each attending physician. Third, on completion of a prospective, randomized trial of the active management of labor in early 1991, this protocol was recommended as the preferred method of labor management for term nulliparous patients.
Results: The total, primary, and repeat cesarean section rates declined from 27.3%, 18.2%, and 9.1% in 1986 to 16.9%, 10.6%, and 6.4%, respectively, in 1991. At the same time the perinatal mortality dropped from 19.5 to 10.3. Significant reductions in abdominal deliveries occurred for both private patients (30.3% to 19.1%, p < 0.0001) and clinic patients (20.8% to 11.5%, p < 0.0001). A decline in operative deliveries for dystocia and an increase in vaginal birth after prior cesarean section were the principal factors contributing to the lower cesarean section rates. However, in 1991 individual private physicians still had wide variations in primary cesarean section rates (4.6% to 21.1%) and use of vaginal birth after prior cesarean section (5.3% to 90%).
Conclusion: The cesarean section rate has been significantly reduced for both private and clinic patients. Differences in population demographics and individual physician practice patterns contributed to a higher incidence of cesarean birth on the private service.